Patient Driven Payment Model - Background & Finalized Changes to the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) - CMS

 
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Patient Driven Payment Model - Background & Finalized Changes to the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) - CMS
Patient Driven Payment Model

   Background & Finalized Changes to
   the Skilled Nursing Facility (SNF)
   Prospective Payment System (PPS)
Patient Driven Payment Model - Background & Finalized Changes to the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) - CMS
Disclaimer

This presentation was prepared as a tool to assist providers and is not intended to
grant rights or impose obligations. Although every reasonable effort has been made
to assure the accuracy of the information within these pages, the ultimate
responsibility for the correct submission of claims and responses to any remittance
advice lies with the provider of services.

This publication is a general summary that explains certain aspects of the Medicare
Program, but is not a legal document. The official Medicare Program provisions are
contained in the relevant laws, regulations, and rulings. Medicare policy changes
frequently, and links to the source documents have been provided within the
document for your reference.

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff
make no representation, warranty, or guarantee that this compilation of Medicare
information is error-free and will bear no responsibility or liability for the results or
consequences its use.

                                                                                            2
Project Overview

• Issues with the current case-mix model, the Resource Utilization
  Groups, Version IV (RUG-IV), have been identified by CMS, OIG,
  MedPAC, the media, and others
      – Therapy payments under the SNF PPS are based primarily on the
         amount of therapy provided to a patient, regardless of the
         patient’s unique characteristics, needs or goals

• The Patient Driven Payment Model (PDPM) represents a marked
  improvement over the RUG-IV model for the following reasons:
   – Improves payment accuracy and appropriateness by focusing on the
     patient, rather than the volume of services provided
   – Significantly reduces administrative burden on providers
   – Improves SNF payments to currently underserved beneficiaries
     without increasing total Medicare payments

                                                                        3
RUG-IV Components

• RUG-IV consists of two case-mix adjusted components:
   – Therapy: Based on volume of services provided
   – Nursing: The nursing case-mix index (CMI) does not currently reflect
     specific variations in non-therapy ancillary utilization

                                                                            4
PDPM Components

• PDPM consists of five case-mix adjusted components, all based on data-
  driven, stakeholder-vetted patient characteristics:
   – Physical Therapy (PT)
   – Occupational Therapy (OT)
   – Speech Language Pathology (SLP)
   – Non-Therapy Ancillary (NTA)
   – Nursing

• PDPM also includes a “variable per diem (VPD) adjustment” that adjusts
  the per diem rate over the course of the stay

                                                                           5
PDPM Snapshot

                6
RUG-IV vs. PDPM

• While RUG-IV (left) reduces everything about a patient to a single, typically
  volume-driven, case-mix group, PDPM (right) focuses on the unique,
  individualized needs, characteristics, and goals of each patient

                                                                              7
Effect of PDPM

• By addressing each individual patient’s unique needs independently,
  PDPM improves payment accuracy and encourages a more patient-driven
  care model

                                                                    8
PDPM Patient Classification

• Under PDPM, each patient is classified into a group for each of the five
  case-mix adjusted components: PT, OT, SLP, NTA, and Nursing

• Each component utilizes different criteria as the basis for patient
  classification:
   – PT: Clinical Category, Functional Score
   – OT: Clinical Category, Functional Score
   – SLP: Presence of Acute Neurologic Condition, SLP-related
      Comorbidity or Cognitive Impairment, Mechanically-altered Diet,
      Swallowing Disorder
   – NTA: NTA Comorbidity Score
   – Nursing: Same characteristics as under RUG-IV

                                                                             9
PT & OT Components: RUG-IV & PDPM

• Under RUG-IV, the number of PT, OT, and SLP therapy treatment minutes
  are combined for a total number of treatment minutes that is used to
  classify a given patient into a given therapy RUG

• Under PDPM, patient characteristics will be used to predict the therapy
  costs associated with a given patient, rather than rely on service use

• For the PT & OT components, two classifications are used:
   – Clinical Category
   – Functional Status

                                                                            10
PDPM Clinical Categories

• SNF patients are first classified into a clinical category based on the
  primary diagnosis for the SNF stay
• ICD-10-CM codes, coded on the MDS in Item I0020B, are mapped to a
  PDPM clinical category
   – Clinical classification may be adjusted by a surgical procedure that
     occurred during the prior inpatient stay, as coded in Section J
   – ICD-10 mapping available at: https://www.cms.gov/Medicare/Medicare-
     Fee-for-Service-Payment/SNFPPS/PDPM.html
                                  PDPM Clinical Categories
   Major Joint Replacement or Spinal Surgery                     Cancer
   Non-Surgical Orthopedic/Musculoskeletal                     Pulmonary
    Orthopedic Surgery (Except Major Joint
                                                   Cardiovascular and Coagulations
     Replacement or Spinal Surgery)
               Acute Infections                              Acute Neurologic
             Medical Management                        Non-Orthopedic Surgery

                                                                                     11
PT & OT Clinical Categories

• Based on data showing similar costs among certain clinical categories, the
  PT & OT components use four collapsed clinical categories for patient
  classification.
        PDPM Clinical Categories                   PT & OT Clinical Categories
 Major Joint Replacement or Spinal Surgery   Major Joint Replacement or Spinal Surgery
             Acute Neurologic
                                             Non-Orthopedic Surgery & Acute Neurologic
         Non-Orthopedic Surgery
  Non-Surgical Orthopedic/Musculoskeletal
  Orthopedic Surgery (Except Major Joint                 Other Orthopedic
      Replacement or Spinal Surgery)
           Medical Management
                  Cancer
                Pulmonary                              Medical Management
      Cardiovascular & Coagulations
             Acute Infections

                                                                                         12
PT & OT Functional Score

• PDPM advances CMS’ goal of using standardized assessment items
  across payment settings, by using items in Section GG of the MDS as the
  basis for patient functional assessments.

• The functional score for the PT & OT components is calculated as the sum
  of the scores on ten Section GG items:
   – Two bed mobility items
   – Three transfer items
   – One eating item
   – One toileting item
   – One oral hygiene item
   – Two walking items

                                                                        13
PT & OT Functional Score: GG Items

• Section GG items included in the PT & OT functional score
 Section GG Item                                        Functional Score Range
 GG0130A1 – Self-care: Eating                                   0–4
 GG0130B1 – Self-care: Oral Hygiene                             0–4
 GG0130C1 – Self-care: Toileting Hygiene                        0–4
 GG0170B1 – Mobility: Sit to Lying                              0–4
 GG0170C1 – Mobility: Lying to Sitting on side of bed    (average of 2 items)
 GG0170D1 – Mobility: Sit to Stand
                                                                0–4
 GG0170E1 – Mobility: Chair/bed-to-chair transfer
                                                         (average of 3 items)
 GG0170F1 – Mobility: Toilet Transfer
 GG0170J1 – Mobility: Walk 50 feet with 2 turns                 0–4
 GG0170K1 – Mobility: Walk 150 feet                      (average of 2 items)

                                                                                 14
Nursing Functional Score: GG Items

• Section GG items included in the Nursing functional score
 Section GG Item                                        Functional Score Range
 GG0130A1 – Self-care: Eating                                   0–4
 GG0130C1 – Self-care: Toileting Hygiene                        0–4
 GG0170B1 – Mobility: Sit to Lying                              0–4
 GG0170C1 – Mobility: Lying to Sitting on side of bed    (average of 2 items)
 GG0170D1 – Mobility: Sit to Stand
                                                                0–4
 GG0170E1 – Mobility: Chair/bed-to-chair transfer
                                                         (average of 3 items)
 GG0170F1 – Mobility: Toilet Transfer

                                                                                 15
Functional Score: Item Response Crosswalk

• PT & OT and Nursing Functional Score Construction (Non-walking Items)
Item Response                                                                            Score
05, 06 – Set-up Assistance, Independent                                                   4
04 – Supervision or touching assistance                                                   3
03 – Partial/Moderate assistance                                                          2
02 – Substantial/Maximal assistance                                                       1
01, 07, 09, 10, 88, missing – Dependent, Refused, Not applicable, Not attempted due to
                                                                                          0
environmental limitations, Not Attempted due to medical condition or safety concerns

• PT & OT Functional Score Construction (Walking Items)
Item Response                                                                            Score
05, 06 – Set-up Assistance, Independent                                                   4
04 – Supervision or touching assistance                                                   3
03 – Partial/Moderate assistance                                                          2
02 – Substantial/Maximal assistance                                                       1
01, 07, 09, 10, 88 – Dependent, Refused, Not applicable, Not attempted due to
environmental limitations, Not Attempted due to medical condition or safety concerns,     0
Resident Cannot Walk (Coded based on response to GG0170I1)
                                                                                                 16
RUG-IV & PDPM Function Score Differences

• Notable differences between G and GG scoring methodologies:
   – Reverse scoring methodology:
      • Under Section G, increasing score means increasing dependence
      • Under Section GG, increasing score means increasing
        independence
   – Non-linear relationship to payment:
      • Under RUG-IV, increasing dependence, within a given RUG
        category, translates to higher payment
      • Under PDPM, there is not a direct relationship between increasing
        dependence and increasing payment
           – Example: For the PT & OT component, payment for three
              clinical categories is lower for the most and least dependent
              patients (who are less likely to require high therapy amounts of
              therapy), compared to those in between (who are more likely to
              require high amounts of therapy)
                                                                            17
PT & OT Components: Payment Groups

                                                 PT & OT          PT & OT
              Clinical Category                                                 PT CMI   OT CMI
                                              Function Score   Case Mix Group
 Major Joint Replacement or Spinal Surgery        0-5                TA          1.53    1.49
 Major Joint Replacement or Spinal Surgery        6-9                TB          1.69    1.63
 Major Joint Replacement or Spinal Surgery       10-23               TC          1.88    1.68
 Major Joint Replacement or Spinal Surgery         24                TD          1.92    1.53
             Other Orthopedic                     0-5                TE          1.42    1.41
             Other Orthopedic                     6-9                TF          1.61    1.59
             Other Orthopedic                    10-23               TG          1.67    1.64
             Other Orthopedic                      24                TH          1.16    1.15
           Medical Management                     0-5                TI          1.13    1.17
           Medical Management                     6-9                TJ          1.42    1.44
           Medical Management                    10-23               TK          1.52    1.54
           Medical Management                      24                TL          1.09    1.11
Non-Orthopedic Surgery and Acute Neurologic       0-5               TM           1.27    1.30
Non-Orthopedic Surgery and Acute Neurologic       6-9                TN          1.48    1.49
Non-Orthopedic Surgery and Acute Neurologic      10-23               TO          1.55    1.55
Non-Orthopedic Surgery and Acute Neurologic        24                TP          1.08    1.09

                                                                                                18
SLP Component

• For the SLP component, PDPM uses a number of different patient
  characteristics that were predictive of increased SLP costs:
   – Acute Neurologic clinical classification
   – Certain SLP-related comorbidities
   – Presence of cognitive impairment
   – Use of a mechanically-altered diet
   – Presence of swallowing disorder

                                                                   19
SLP Comorbidities

• Twelve SLP comorbidities were identified as predictive of higher SLP costs
   – Conditions and services combined into a single SLP-related
     comorbidity flag
   – Patient qualifies if any of the conditions/services is present

                                      SLP Comorbidities
                 Aphasia                                      Laryngeal Cancer
           CVA,TIA, or Stroke                                      Apraxia
        Hemiplegia or Hemiparesis                                 Dysphagia
          Traumatic Brain Injury                                     ALS
      Tracheostomy (while Resident)                             Oral Cancers
        Ventilator (while Resident)                       Speech & Language Deficits

                                                                                       20
PDPM Cognitive Scoring
• Under RUG-IV, a patient’s cognitive status is assessed using the Brief
  Interview for Mental Status (BIMS)
   – In cases where the BIMS cannot be completed, providers are required
      to perform a staff assessment for mental status
   – The Cognitive Performance Scale (CPS) is then used to score the
      patient’s cognitive status based on the results of the staff assessment

• Under PDPM, a patient’s cognitive status is assessed in exactly the same
  way as under RUG-IV (i.e., via the BIMS or staff assessment)
   – Scoring the patient’s cognitive status, for purposes of classification, is
     based on the Cognitive Function Scale (CFS), which is able to provide
     consistent scoring across the BIMS and staff assessment

                                                                              21
PDPM Cognitive Score: Methodology
• PDPM Cognitive Measure Classification Methodology

Cognitive Level                                 BIMS Score   CPS Score
Cognitively Intact                                13 – 15       0
Mildly Impaired                                   8 – 12       1–2
Moderately Impaired                                0–7         3–4
Severely Impaired                                     -        5–6

                                                                         22
SLP Component: Payment Groups

   Presence of Acute Neurologic       Mechanically Altered
                                                             SLP Case    SLP Case Mix
Condition, SLP Related Comorbidity,    Diet or Swallowing
                                                             Mix Group       Index
     or Cognitive Impairment                Disorder

              None                          Neither             SA           0.68
              None                           Either             SB           1.82
              None                           Both               SC           2.66
             Any one                        Neither             SD           1.46
             Any one                         Either             SE           2.33
             Any one                         Both               SF           2.97
             Any two                        Neither             SG           2.04
             Any two                         Either             SH           2.85
             Any two                         Both               SI           3.51
             All three                      Neither             SJ           2.98
             All three                       Either             SK           3.69
             All three                       Both               SL           4.19

                                                                                    23
NTA Component

• NTA classification is based on the presence of certain comorbidities or
  use of certain extensive services

• We considered various options to incorporate comorbidities into payment.
  – Total number of comorbidities is linked to NTA costs, but a simple
    count of conditions overlooks differences in relative costliness
  – A tier system accounts for differences in relative costliness, but does
    not account for the number of comorbidities

• Comorbidity score is a weighted count of comorbidities
   – Comorbidities associated with high increases in NTA costs grouped
     into various point tiers
   – Points assigned for each additional comorbidity present, with more
     points awarded for higher-cost tiers

                                                                            24
NTA Component: Comorbidity Coding

• Comorbidities and extensive services for NTA classification are derived
  from a variety of MDS sources, with some comorbidities identified by ICD-
  10-CM codes reported in Item I8000

• A mapping between ICD-10-CM codes and NTA comorbidities used for
  NTA classification is available on the CMS website at:
  https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
  Payment/SNFPPS/PDPM.html

• One comorbidity (HIV/AIDS) is reported on the SNF claim, in the same
  manner as under RUG-IV
   – The patient’s NTA classification will be adjusted by the appropriate
     number of points for this condition by the CMS PRICER for patients
     with HIV/AIDS

                                                                            25
NTA Component: Condition Listing (1)
                   Condition/Extensive Service                             Source        Points
HIV/AIDS                                                             SNF Claim             8
                                                                     MDS Item K0510A2,
Parenteral IV Feeding: Level High                                                          7
                                                                     K0710A2
Special Treatments/Programs: Intravenous Medication Post-admit
                                                                     MDS Item O0100H2      5
Code
Special Treatments/Programs: Ventilator or Respirator Post-admit
                                                                     MDS Item O0100F2      4
Code
                                                                     MDS Item K0510A2,
Parenteral IV feeding: Level Low                                                           3
                                                                     K0710A2, K0710B2
Lung Transplant Status                                               MDS Item I8000        3
Special Treatments/Programs: Transfusion Post-admit Code             MDS Item O0100I2      2
Major Organ Transplant Status, Except Lung                           MDS Item I8000        2
Multiple Sclerosis Code                                              MDS Item I5200        2
Opportunistic Infections                                             MDS Item I8000        2
Asthma COPD Chronic Lung Disease Code                                MDS Item I6200        2
Bone/Joint/Muscle Infections/Necrosis - Except Aseptic Necrosis of
                                                                     MDS Item I8000        2
Bone
Chronic Myeloid Leukemia                                             MDS Item I8000        2
Wound Infection Code                                                 MDS Item I2500        2
Diabetes Mellitus (DM) Code                                          MDS Item I2900        2
                                                                                                  26
NTA Component: Condition Listing (2)
                   Condition/Extensive Service                         Source       Points
Endocarditis                                                     MDS Item I8000       1
Immune Disorders                                                 MDS Item I8000       1
End-Stage Liver Disease                                          MDS Item I8000       1
Other Foot Skin Problems: Diabetic Foot Ulcer Code               MDS Item M1040B      1
Narcolepsy and Cataplexy                                         MDS Item I8000       1
Cystic Fibrosis                                                  MDS Item I8000       1
Special Treatments/Programs: Tracheostomy Care Post-admit Code   MDS Item O0100E2     1
Multi-Drug Resistant Organism (MDRO) Code                        MDS Item I1700       1
Special Treatments/Programs: Isolation Post-admit Code           MDS Item O0100M2     1
Specified Hereditary Metabolic/Immune Disorders                  MDS Item I8000       1
Morbid Obesity                                                   MDS Item I8000       1
Special Treatments/Programs: Radiation Post-admit Code           MDS Item O0100B2     1
Highest Stage of Unhealed Pressure Ulcer - Stage 4               MDS Item M0300D1     1
Psoriatic Arthropathy and Systemic Sclerosis                     MDS Item I8000       1
Chronic Pancreatitis                                             MDS Item I8000       1
Proliferative Diabetic Retinopathy and Vitreous Hemorrhage       MDS Item I8000       1

                                                                                             27
NTA Component: Condition Listing (3)
                   Condition/Extensive Service                               Source       Points
Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on    MDS Item M1040A,
                                                                                            1
Foot Code, Except Diabetic Foot Ulcer Code                             M1040B, M1040C
Complications of Specified Implanted Device or Graft                   MDS Item I8000       1
Bladder and Bowel Appliances: Intermittent Catheterization             MDS Item H0100D      1
Inflammatory Bowel Disease                                             MDS Item I1300       1
Aseptic Necrosis of Bone                                               MDS Item I8000       1
Special Treatments/Programs: Suctioning Post-admit Code                MDS Item O0100D2     1
Cardio-Respiratory Failure and Shock                                   MDS Item I8000       1
Myelodysplastic Syndromes and Myelofibrosis                            MDS Item I8000       1
Systemic Lupus Erythematosus, Other Connective Tissue Disorders,
                                                                       MDS Item I8000       1
and Inflammatory Spondylopathies
Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and
                                                                       MDS Item I8000       1
Vitreous Hemorrhage
Nutritional Approaches While a Resident: Feeding Tube                  MDS Item K0510B2     1
Severe Skin Burn or Condition                                          MDS Item I8000       1
Intractable Epilepsy                                                   MDS Item I8000       1
Malnutrition Code                                                      MDS Item I5600       1

                                                                                                   28
NTA Component: Condition Listing (4)
                  Condition/Extensive Service                     Source      Points

Disorders of Immunity - Except : RxCC97: Immune Disorders   MDS Item I8000      1
Cirrhosis of Liver                                          MDS Item I8000      1
Bladder and Bowel Appliances: Ostomy                        MDS Item H0100C     1
Respiratory Arrest                                          MDS Item I8000      1
Pulmonary Fibrosis and Other Chronic Lung Disorders         MDS Item I8000      1

                                                                                       29
NTA Component: Payment Groups

NTA Score Range   NTA Case Mix Group   NTA Case Mix Index
      12+                 NA                  3.25
     9-11                 NB                  2.53
      6-8                 NC                  1.85
      3-5                 ND                  1.34
      1-2                 NE                  0.96
       0                  NF                  0.72

                                                            30
Nursing Component

• RUG-IV classifies patients into a therapy RUG, based on how much
  therapy the patient receives, and a non-therapy RUG, based on certain
  patient characteristics.
   – Only one of these RUGs is used for payment purposes
   – Therapy RUGs are used to bill for over 90% of Part A days

• Therapy RUGs use a consistent nursing case-mix adjustment, which
  obscures clinically meaningful differences in nursing characteristics
  between patients in the same therapy RUG.

• PDPM utilizes the same basic nursing classification structure as RUG-IV,
  with certain modifications.
   – Function score based on Section GG of the MDS 3.0
   – Collapsed functional groups, reducing the number of nursing groups
      from 43 to 25
                                                                             31
Nursing Component: Payment Groups (1)
RUG-IV                                                                       Restorative
              Extensive                                                                  Function
Nursing                               Clinical Conditions         Depression  Nursing               CMG    CMI
               Services                                                                   Score
 RUG                                                                          Services
          Tracheostomy &
  ES3                                                                                      0-14     ES3    4.04
             Ventilator
          Tracheostomy or
  ES2                                                                                      0-14     ES2    3.06
             Ventilator
  ES1     Infection Isolation                                                              0-14     ES1    2.91
                                Serious medical conditions e.g.
HE2/HD2                             comatose, septicemia,            Yes                   0-5      HDE2   2.39
                                      respiratory therapy
                                Serious medical conditions e.g.
HE1/HD1                             comatose, septicemia,            No                    0-5      HDE1   1.99
                                      respiratory therapy
                                Serious medical conditions e.g.
HC2/HB2                             comatose, septicemia,            Yes                   6-14     HBC2   2.23
                                      respiratory therapy
                                Serious medical conditions e.g.
HC1/HB1                             comatose, septicemia,            No                    6-14     HBC1   1.85
                                      respiratory therapy

                                                                                                             32
Nursing Component: Payment Groups (2)
RUG-IV                                                                       Restorative
          Extensive                                                                      Function
Nursing                         Clinical Conditions               Depression  Nursing               CMG    CMI
           Services                                                                       Score
 RUG                                                                          Services
                      Serious medical conditions e.g. radiation
LE2/LD2                                                              Yes                   0-5      LDE2   2.07
                                  therapy or dialysis
                      Serious medical conditions e.g. radiation
LE1/LD1                                                              No                    0-5      LDE1   1.72
                                  therapy or dialysis
                      Serious medical conditions e.g. radiation
LC2/LB2                                                              Yes                   6-14     LBC2   1.71
                                  therapy or dialysis
                      Serious medical conditions e.g. radiation
LC1/LB1                                                              No                    6-14     LBC1   1.43
                                  therapy or dialysis
                       Conditions requiring complex medical
CE2/CD2                care e.g. pneumonia, surgical wounds,         Yes                   0-5      CDE2   1.86
                                        burns
                       Conditions requiring complex medical
CE1/CD1                care e.g. pneumonia, surgical wounds,         No                    0-5      CDE1   1.62
                                        burns
                       Conditions requiring complex medical
CC2/CB2                care e.g. pneumonia, surgical wounds,         Yes                   6-14     CBC2   1.54
                                        burns
                       Conditions requiring complex medical
 CA2                   care e.g. pneumonia, surgical wounds,         Yes                  15-16     CA2    1.08
                                        burns

                                                                                                             33
Nursing Component: Payment Groups (3)
RUG-IV                                                                      Restorative
          Extensive                                                                     Function
Nursing                         Clinical Conditions              Depression  Nursing               CMG    CMI
           Services                                                                      Score
 RUG                                                                         Services
                      Conditions requiring complex medical
CC1/CB1               care e.g. pneumonia, surgical wounds,         No                    6-14     CBC1   1.34
                                      burns
                      Conditions requiring complex medical
 CA1                  care e.g. pneumonia, surgical wounds,         No                   15-16     CA1    0.94
                                      burns
BB2/BA2                 Behavioral or cognitive symptoms                     2 or more   11-16     BAB2   1.04
BB1/BA1                 Behavioral or cognitive symptoms                        0-1      11-16     BAB1   0.99
                      Assistance with daily living and general
PE2/PD2                                                                      2 or more    0-5      PDE2   1.57
                                   supervision
                      Assistance with daily living and general
PE1/PD1                                                                         0-1       0-5      PDE1   1.47
                                   supervision
                      Assistance with daily living and general
PC2/PB2                                                                      2 or more    6-14     PBC2   1.21
                                   supervision
                      Assistance with daily living and general
  PA2                                                                        2 or more   15-16     PA2    0.7
                                   supervision
                      Assistance with daily living and general
PC1/PB1                                                                         0-1       6-14     PBC1   1.13
                                   supervision
                      Assistance with daily living and general
  PA1                                                                           0-1      15-16     PA1    0.66
                                   supervision

                                                                                                            34
Variable Per Diem Adjustment

• The Social Security Act requires the SNF PPS to pay on a per-diem basis.

• Constant per diem rates do not accurately track changes in resource
  utilization throughout the stay, and may allocate too few resources for
  providers at beginning of stay.

• To account more accurately for the variability in patient costs over the
  course of a stay, under PDPM, an adjustment factor is applied (for certain
  components) and changes the per diem rate over the course of the stay.
   – Similar to what exists under the Inpatient Psychiatric Facility (IPF) PPS

• For the PT, OT, and NTA components, the case-mix adjusted per diem rate
  is multiplied against the variable per diem adjustment factor, following a
  schedule of adjustments for each day of the patient’s stay.

                                                                            35
Variable Per Diem Adjustment Schedules

• PT & OT Components
    Day in Stay   Adjustment Factor   Day in Stay   Adjustment Factor
       1-20             1.00            63-69             0.86
      21-27             0.98            70-76             0.84
      28-34             0.96            77-83             0.82
      35-41             0.94            84-90             0.80
      42-48             0.92            91-97             0.78
      49-55             0.90            98-100            0.76
      56-62             0.88
• NTA Component

    Day in Stay   Adjustment Factor
       1-3              3.00
      4-100             1.00

                                                                        36
Patient Classification Example

• Consider two patients with the following characteristics:
Patient Characteristics             Patient A                    Patient B
Rehabilitation Received?               Yes                          Yes
Therapy Minutes                        730                          730
Extensive Services                     No                            No
ADL Score                               9                             9
Clinical Category                Acute Neurologic         Major Joint Replacement
PT & OT Functional Score                10                           10
Nursing Function Score                  7                             7
Cognitive Impairment                Moderate                       Intact
Swallowing Disorder?                   No                            No
Mechanically Altered Diet?             Yes                           No
SLP Comorbidity?                       No                            No
Comorbidities                IV Medication and Diabetes     Chronic Pancreatitis
Other Conditions                      Dialysis                  Septicemia
Depression?                             No                         Yes

                                                                                    37
RUG-IV Classification
• Under the RUG-IV model, both patients would be classified into the same
  payment group because they received the same number of therapy
  minutes and received no extensive services, despite significant differences
  between them.

                                                                           38
PDPM Classification: PT & OT Components

• Patient A (left) is classified into Acute Neurologic with PT and OT
  Functional Score of 10; Patient B (right) is classified into Major Joint
  Replacement/Spinal Surgery with a PT and OT Functional Score of 10.

                                                                             39
PDPM Classification: SLP Component

• Patient A (left) is classified into Acute Neurologic, has moderate cognitive
  impairment, and is on a mechanically-altered diet; and Patient B (right) is
  classified into non-neurologic with no SLP-classification related issue.

                                                                                 40
PDPM Classification: NTA Component

• Patient A (left) has an NTA Comorbidity Score of 7 from IV medication (5
  points) and diabetes mellitus (2 points); Patient B (right) has an NTA
  Comorbidity Score of 1 from chronic pancreatitis (1 point).

                                                                             41
PDPM Classification: Nursing Component (1)

• Patient A is receiving dialysis services with a Nursing Function Score of 7
  and is classified into LBC1.
   Extensive
                                Extensive Services                     PDPM Nursing Function Score
   Services?

                                    Ventilator/      Infection   0-1          2-5         6-10          11-14   15-16
                 Tracheostomy
                                    Respirator       Isolation

                                                                                  ES3

                                         
      Yes                                                                           ES2
                                         

                                                                                 ES1

                  Other Conditions                Depression?
                    Serious medical                   Yes              HDE2                      HBC2
                     conditions e.g.
                 comatose, septicemia,                No               HDE1                      HBC1
                  respiratory therapy
                    Serious medical
                                                      Yes              LDE2                      LBC2
                     conditions e.g.
                  radiation therapy or
                         dialysis                     No               LDE1                      LBC1

                  Conditions requiring
                 complex medical care                 Yes              CDE2                      CBC2           CA2
      No
                  such as pneumonia,
                 surgical wounds, burns               No               CDE1                      CBC1           CA1

                                                                                                                        42
PDPM Classification: Nursing Component (2)

• Patient B has septicemia and a Nursing Function Score of 7, exhibits signs
  of depression, and is classified into HBC2.
   Extensive
                               Extensive Services                     PDPM Nursing Function Score
   Services?

                                   Ventilator/      Infection   0-1          2-5         6-10          11-14   15-16
                Tracheostomy
                                   Respirator       Isolation

                                                                                 ES3

                                        
      Yes                                                                          ES2
                                        

                                                                                ES1

                 Other Conditions                Depression?
                   Serious medical                   Yes              HDE2                      HBC2
                    conditions e.g.
                comatose, septicemia,                No               HDE1                      HBC1
                 respiratory therapy
                   Serious medical
                                                     Yes              LDE2                      LBC2
                    conditions e.g.
                 radiation therapy or
                        dialysis                     No               LDE1                      LBC1

                 Conditions requiring
                complex medical care                 Yes              CDE2                      CBC2           CA2
      No
                 such as pneumonia,
                surgical wounds, burns               No               CDE1                      CBC1           CA1

                                                                                                                       43
Additional PDPM Policies

• In addition to the case-mix refinements, PDPM also includes policy
  changes to the SNF PPS to be effective concurrent with implementation of
  PDPM.

• The areas discussed in the next slides are:
   – MDS Related Changes:
       • MDS Assessment Schedule
       • New MDS Item Sets
       • New MDS Items
   – Concurrent & Group Therapy Limit
   – Interrupted Stay Policy
   – Administrative Presumption
   – Payment for Patients with AIDS
   – Revised HIPPS Coding
   – RUG-IV – PDPM Transition

                                                                        44
MDS Changes: Assessment Schedule

• Both RUG-IV and PDPM utilize the MDS 3.0 as the basis for patient
  assessment and classification.

• The assessment schedule for RUG-IV includes both scheduled and
  unscheduled assessments with a variety of rules governing timing,
  interaction among assessments, combining assessments, etc.
   – Frequent assessments are necessary, due to the focus of RUG-IV on
      such highly variable characteristics as service utilization

• The assessment schedule under PDPM is significantly more streamlined
  and simple to understand than the assessment schedule under RUG-IV.

• The changes to the assessment schedule under PDPM have no effect on
  any OBRA-related assessment requirements.

                                                                         45
RUG-IV Assessment Schedule

• RUG-IV PPS Assessment Schedule
Scheduled Assessment
     Medicare MDS            Assessment          Assessment Reference           Applicable Standard Medicare
Assessment Schedule Type    Reference Date          Date Grace Days                    Payment Days
         5-day                 Days 1-5                   6-8                            1 through 14
        14-day                Days 13-14                 15-18                          15 through 30
        30-day                Days 27-29                 30-33                          31 through 60
        60-day                Days 57-59                 60-63                          61 through 90
        90-day                Days 87-89                 90-93                         91 through 100
Unscheduled Assessment
 Start of Therapy OMRA       5-7 days after         start of therapy    Date of the first day of therapy through the
                                                                        end of the standard payment period
  End of Therapy OMRA        1-3 days after         end of therapy      First non-therapy day through the end of the
                                                                        standard payment period
                                                                        The first day of the COT observation period
                                                                        until end of standard payment period, or until
Change of Therapy OMRA     Day 7 (last day) of     COT observation
                                                       period           interrupted by the next COT-OMRA
                                                                        assessment or scheduled or unscheduled PPS
                                                                        Assessment
  Significant Change in    No later than 14        significant change   ARD of Assessment through the end of the
   Status Assessment          days after               identified       standard payment period

                                                                                                                    46
PDPM Assessment Schedule

• PDPM Assessment Schedule

Medicare MDS Assessment      Assessment Reference Date          Applicable Standard
     Schedule Type                                             Medicare Payment Days

                                                             All covered Part A days until
  Five-day Scheduled PPS              Days 1-8
        Assessment                                          Part A discharge (unless an IPA
                                                                     is completed)
                                                               ARD of the assessment
Interim Payment Assessment      Optional Assessment           through Part A discharge
           (IPA)                                                 (unless another IPA
                                                              assessment is completed)
                              PPS Discharge: Equal to the
 PPS Discharge Assessment    End Date of the Most Recent                 N/A
                              Medicare Stay (A2400C) or
                                       End Date

                                                                                         47
MDS Changes: New Item Sets

• Interim Payment Assessment (IPA)
   – Optional Assessment: May be completed by providers in order to
      report a change in the patient’s PDPM classification
        • Does not impact the variable per diem schedule
   – ARD: Determined by the provider
   – Payment Impact: Changes payment beginning on the ARD and
      continues until the end of the Part A stay or until another IPA is
      completed

• Optional State Assessment (OSA)
   – Solely to be used by providers to report on Medicaid-covered stays,
     per requirements set forth by their state
   – Allows providers in states using RUG-III or RUG-IV models as the
     basis for Medicaid payment to do so until September 30, 2020, at
     which point CMS support for legacy payment models will end.
                                                                           48
MDS Changes: New & Revised Items (1)

• SNF Primary Diagnosis
   – Item I0020B (New Item)
   – This item is for providers to report, using an ICD-10-CM code, the
     patient’s primary SNF diagnosis
   – “What is the main reason this person is being admitted to the SNF?”
   – Coded when I0020 is coded as any response 1 – 13

• Patient Surgical History
   – Items J2100 – J5000 (New Items)
   – These items are used to capture any major surgical procedures that
     occurred during the inpatient hospital stay that immediately preceded
     the SNF admission (i.e., the qualifying hospital stay)
   – Similar to the active diagnoses captured in Section I, these Section J
     items will be in the form of checkboxes

                                                                              49
MDS Changes: Patient Surgical Categories
Item             Surgical Procedure Category                    Item            Surgical Procedure Category
J2100   Recent Surgery Requiring Active SNF Care                J2610 Neuro surgery - peripheral and autonomic nervous
                                                                      system - open and percutaneous
J2300   Knee Replacement - partial or total                     J2620 Neuro surgery - insertion or removal of spinal and
                                                                      brain neurostimulators, electrodes, catheters, and
                                                                      CSF drainage devices
J2310   Hip Replacement - partial or total                      J2699 Neuro surgery - other
J2320   Ankle Replacement - partial or total                    J2700 Cardiopulmonary surgery - heart or major blood
                                                                      vessels - open and percutaneous procedures
J2330   Shoulder Replacement - partial or total                 J2710 Cardiopulmonary surgery - respiratory system,
                                                                      including lungs, bronchi, trachea, larynx, or vocal
                                                                      cords - open and endoscopic
J2400   Spinal surgery - spinal cord or major spinal nerves     J2799 Cardiopulmonary surgery - other
J2410   Spinal surgery - fusion of spinal bones                 J2800 Genitourinary surgery - male or female organs
J2420   Spinal surgery - lamina, discs, or facets               J2810 Genitourinary surgery - kidneys, ureter, adrenals,
                                                                      and bladder - open, laparoscopic
J2499   Spinal surgery - other                                  J2899 Genitourinary surgery - other
J2500   Ortho surgery - repair fractures of shoulder or arm     J2900 Major surgery - tendons, ligament, or muscles
J2510   Ortho surgery - repair fractures of pelvis, hip, leg,   J2910 Major surgery - GI tract and abdominal contents
        knee, or ankle                                                from esophagus to anus, biliary tree, gall bladder,
                                                                      liver, pancreas, spleen - open, laparoscopic
J2520   Ortho surgery - repair but not replace joints           J2920 Major surgery - endocrine organs (such as thyroid,
                                                                      parathyroid), neck, lymph nodes, and thymus - open
J2530   Ortho surgery - repair other bones                      J2930 Major surgery - breast
J2599   Ortho surgery - other                                   J2940 Major surgery - deep ulcers, internal brachytherapy,
                                                                      bone marrow, stem cell harvest/transplant
J2600   Neuro surgery - brain, surrounding tissue/blood         J5000 Major surgery - other not listed above
        vessels                                                                                                       50
MDS Changes: New & Revised Items (2)

• Discharge Therapy Collection Items
   – Items 0425A1 – O0425C5 (New Items)
   – Using a look-back of the entire PPS stay, providers report, by each
     discipline and mode of therapy, the amount of therapy (in minutes)
     received by the patient
   – If the total amount of group/concurrent minutes, combined, comprises
     more than 25% of the total amount of therapy for that discipline, a
     warning message is issued on the final validation report

• Section GG Functional Items – Interim Performance
   – On the IPA, Section GG items will be derived from a new column “5”
     which will capture the interim performance of the patient
   – The look-back for this new column will be the three-day window
     leading up to and including the ARD of the IPA (ARD and the 2
     calendar days prior to the ARD)
                                                                            51
MDS Changes: New & Revised Items (3)

• Existing MDS Items Being Added to Swing Bed Assessment
   – K0100: Swallowing Disorder
   – I1300: Ulcerative Colitis or Crohn’s Disease or Inflammatory Bowel
     Disease
   – I4300: Active Diagnosis: Aphasia
   – O0100D2: Special Treatments, Procedures & Programs: Suctioning,
     While a Resident

• Existing Items Being Added to 5-day PPS Assessment and IPA
   – I1300: Ulcerative Colitis or Crohn’s Disease or Inflammatory Bowel
     Disease

                                                                          52
Concurrent & Group Therapy Limit

• Under RUG-IV, no more than 25% of the therapy services delivered to
  SNF patients, for each discipline, may be provided in a group therapy
  setting, while there is no limit on concurrent therapy.

• Definitions:
   – Concurrent Therapy: One therapist with two patients doing different
     activities
   – Group Therapy: One therapist with four patients doing the same or
     similar activities

• Under PDPM, we use a combined limit both concurrent and group therapy
  to be no more than 25% of the therapy received by SNF patients, for each
  therapy discipline.

                                                                           53
Concurrent & Group Limit: Compliance

• Compliance with the concurrent/group therapy limit will be monitored by
  new items on the PPS Discharge Assessment (O0425).
   – Providers will report the number of minutes, per mode and per
     discipline, for the entirety of the PPS stay
   – If the total number of concurrent and group minutes, combined,
     comprises more than 25% of the total therapy minutes provided to the
     patient, for any therapy discipline, then the provider will receive a
     warning message on their final validation report

• How to calculate compliance with the concurrent/group therapy limit.
   – Step 1: Total Therapy Minutes, by discipline
     (O0425X1 + O0425X2 + O0425X3)
   – Step 2: Total Concurrent and Group Therapy Minutes, by discipline
     (O0425X2 + O0425X3)
   – Step 3: C/G Ratio (Step 2 Result / Step 1 Result)
   – Step 4: If Step 3 Result is greater than 0.25, then non-compliant

                                                                         54
Concurrent & Group Limit: Example 1

• Example 1
   – Total PT Individual Minutes (O0425C1): 2,000
   – Total PT Concurrent Minutes (O0425C2): 600
   – Total PT Group Minutes (O0425C3): 1,000

• Does this comply with the concurrent/group therapy limit?
   – Step 1: Total PT Minutes (O0425C1 + O0425C2 + O0425C3): 3,600
   – Step 2: Total PT Concurrent and Group Therapy Minutes (O0425C2 +
     O0425C3): 1,600
   – Step 3: C/G Ratio (Step 2 Result / Step 1 Result): 0.44
   – Step 4: 0.44 is greater than 0.25, therefore this is non-compliant

                                                                      55
Concurrent & Group Limit: Example 2

• Example 2
   – Total SLP Individual Minutes (O0425C1): 1,200
   – Total SLP Concurrent Minutes (O0425C2): 100
   – Total SLP Group Minutes (O0425C3): 200

• Does this comply with the concurrent/group therapy limit?
   – Step 1: Total SLP Minutes (O0425C1 + O0425C2 + O0425C3): 1,500
   – Step 2: Total PT Concurrent and Group Therapy Minutes (O0425C2 +
     O0425C3): 300
   – Step 3: C/G Ratio (Step 2 Result / Step 1 Result): 0.20
   – Step 4: 0.20 is not greater than 0.25, therefore this is compliant

                                                                      56
Interrupted Stay Policy: Background

• Given the introduction, under PDPM, of the variable per diem adjustment,
  there is a potential incentive for providers to discharge SNF patients from
  a covered Part A stay and then readmit the patient in order to reset the
  variable per diem schedule.

• Frequent patient readmissions and transfers represents a significant risk
  to patient care, as well as a potential administrative burden on providers
  from having to complete new patient assessments for each readmission.

• To mitigate this potential incentive, PDPM includes an interrupted stay
  policy, which would combine multiple SNF stays into a single stay in cases
  where the patient’s discharge and readmission occurs within a prescribed
  window.
   – This type of policy also exists in other post-acute care settings (e.g.,
      Inpatient Rehabilitation Facility (IRF) PPS).

                                                                               57
Interrupted Stay Policy

• If a patient is discharged from a SNF and readmitted to the same SNF no
  more than 3 consecutive calendar days after discharge, then the
  subsequent stay is considered a continuation of the previous stay.
    – Assessment schedule continues from the point just prior to discharge
    – Variable per diem schedule continues from the point just prior to
       discharge

• If patient is discharged from SNF and readmitted more than 3 consecutive
  calendar days after discharge, or admitted to a different SNF, then the
  subsequent stay is considered a new stay.
    – Assessment schedule and variable per diem schedule reset to day 1

                                                                             58
Interrupted Stay Policy: Examples

• Example 1: Patient A is admitted to SNF on 11/07/19, admitted to hospital
  on 11/20/19, and returns to same SNF on 11/25/19
   – New stay
   – Assessment Schedule: Reset; stay begins with new 5-day assessment
   – Variable Per Diem: Reset: stay begins on Day 1 of VPD Schedule
• Example 2: Patient B is admitted to SNF on 11/07/19, admitted to hospital
  on 11/20/19, and admitted to different SNF on 11/22/19
   – New stay
   – Assessment Schedule: Reset; stay begins with new 5-day assessment
   – Variable Per Diem: Reset; stay begins on Day 1 of VPD Schedule
• Example 3: Patient C is admitted to SNF on 11/07/19, admitted to hospital
  on 11/20/19, and returns to same SNF on 11/22/19
   – Continuation of previous stay
   – Assessment Schedule: No PPS assessments required, IPA optional
   – Variable Per Diem: Continues from Day 14 (Day of Discharge)

                                                                          59
Administrative Presumption: Background

• The SNF PPS includes an administrative presumption in which a
  beneficiary who is correctly assigned one of the designated, more
  intensive case-mix classifiers on the 5-day PPS assessment is
  automatically classified as requiring an SNF level of care through the
  assessment reference date for that assessment.

• Those beneficiaries not assigned one of the designated classifiers are not
  automatically classified as either meeting or not meeting the level of care
  definition, but instead receive an individual determination using the
  existing administrative criteria.

                                                                            60
Administrative Presumption: Classifiers

• The following PDPM classifiers are designated under the presumption:
   – Those nursing groups encompassed by the Extensive Services,
     Special Care High, Special Care Low, and Clinically Complex nursing
     categories;
   – PT & OT groups TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO;
   – SLP groups SC, SE, SF, SH, SI, SJ, SK, and SL; and
   – The NTA component’s uppermost (12+) comorbidity group

                                                                           61
RUG-IV Payment for SNF Patients with AIDS

• Under RUG-IV, patients with AIDS receive 128% increase in the per diem
  rate associated with their RUG-IV classification.

• This add-on was merely a general approximation of the added cost of
  caring for patients with AIDS, which was not accurately targeted at the
  specific rate components that actually account for the disparity in cost
  between those patients and others.
   – Two primary cost components that drive increased cost for this
      subpopulation are Nursing and NTA costs
   – Under RUG-IV, given most patients are classified into a therapy group
      and criteria used to classify patients into therapy groups, increased
      therapy utilization also increased impact of the AIDS add-on, contrary
      to research indicating that AIDS is actually associated with a
      statistically significant decrease in per diem therapy costs

                                                                           62
PDPM Payment for SNF Patients with AIDS

• As the PDPM was developed, its rate components were specifically
  designed to account accurately and appropriately for the increased cost of
  AIDS-related care, as determined through our research.

• Accordingly, the PDPM addresses costs for this subpopulation in two
  ways.
   – Assigns those patients with AIDS the highest point value (8 points) of
     any condition or service for purposes of classification under its NTA
     component
   – 18% add-on to the PDPM Nursing component

• As under the previous RUG-IV model, the presence of an AIDS diagnosis
  continues to be identified through the SNF’s entry of ICD-10-CM Code
  B20 on the SNF claim.

                                                                              63
PDPM HIPPS Coding

• Based on responses on the MDS, patients are classified into payment
  groups, which are billed using a 5-character Health Insurance Prospective
  Payment System (HIPPS) code.

• The current RUG-IV HIPPS code follows a prescribed algorithm.
   – Character 1-3: RUG Code
   – Character 4-5: Assessment Indicator

• In order to accommodate the new payment groups, the PDPM HIPPS
  algorithm is revised as follows:
   – Character 1: PT/OT Payment Group
   – Character 2: SLP Payment Group
   – Character 3: NTA Payment Group
   – Character 4: Nursing Payment Group
   – Character 5: Assessment Indicator
                                                                          64
PDPM HIPPS Coding Crosswalk: PT, OT, NTA

 • PT/OT, SLP, NTA Payment Groups to HIPPS Translation
     PT/OT            SLP             NTA          HIPPS
 Payment Group    Payment Group   Payment Group   Character
       TA              SA              NA            A
       TB              SB              NB            B
       TC              SC              NC            C
       TD              SD              ND            D
       TE              SE              NE            E
       TF              SF              NF            F
       TG              SG                            G
       TH              SH                            H
        TI             SI                             I
       TJ              SJ                             J
       TK              SK                            K
       TL              SL                             L
       TM                                            M
       TN                                            N
       TO                                            O
       TP                                            P

                                                              65
PDPM HIPPS Coding Crosswalk: Nursing

• Nursing Payment Group to HIPPS Translation

   Nursing         HIPPS         Nursing        HIPPS
Payment Group     Character   Payment Group    Character
      ES3             A           CBC2            N
      ES2             B            CA2            O
      ES1             C           CBC1            P
     HDE2             D            CA1            Q
     HDE1             E           BAB2            R
     HBC2             F           BAB1            S
     HBC1             G           PDE2            T
     LDE2             H           PDE1            U
     LDE1             I           PBC2            V
     LBC2             J            PA2            W
     LBC1             K           PBC1            X
     CDE2             L            PA1            Y
     CDE1             M

                                                           66
PDPM HIPPS Coding Crosswalk: AI

• Assessment Indicator (AI) Crosswalk

HIPPS Character                    Assessment Type

       0                                   IPA
       1                               PPS 5-day
       6             OBRA Assessment (not coded as a PPS Assessment)

                                                                       67
PDPM HIPPS Coding: Examples

• Example 1:
   – PT/OT Payment Group: TN
   – SLP Payment Group: SH
   – NTA Payment Group: NC
   – Nursing Payment Group: CBC2
   – Assessment Type: 5-day PPS Assessment
   – HIPPS Code: NHCN1

• Example 2:
   – PT/OT Payment Group: TC
   – SLP Payment Group: SD
   – NTA Payment Group: NE
   – Nursing Payment Group: PBC1
   – Assessment Type: 5-day PPS Assessment
   – HIPPS Code:CDEX1

                                             68
RUG-IV & PDPM Transition

• As discussed in the FY 2019 SNF PPS Final Rule, there is no transition
  period between RUG-IV and PDPM, given that running both systems at
  the same time would be administratively infeasible for providers and CMS.
   – RUG-IV billing ends September 30, 2019
   – PDPM billing begins October 1, 2019

• To receive a PDPM HIPPS code that can be used for billing beginning
  October 1, 2019, all providers will be required to complete an IPA with an
  ARD no later than October 7, 2019 for all SNF Part A patients.
   – October 1, 2019 will be considered Day 1 of the VPD schedule under
      PDPM, even if the patient began their stay prior to October 1, 2019.
   – Any “transitional IPAs” with an ARD after October 7, 2019 will be
      considered late and relevant penalty for late assessments would apply

                                                                           69
Medicaid Related Issues: UPL

• PDPM may have a number of effects on Medicaid programs.
   – Upper Payment Limit (UPL) Calculation
   – Case-mix Determinations

• UPL represents a limit on certain reimbursements for Medicaid providers.
   – Specifically, the UPL is the maximum a given State Medicaid program
     may pay a type of provider, in the aggregate, statewide in Medicaid
     fee-for-service (FFS)
   – State Medicaid programs cannot claim federal matching dollars for
     provider payments in excess of the applicable UPL

• While budget neutral in the aggregate, PDPM changes how payment is
  made for SNF services, which can have an impact on UPL calculations.
   – States will need to evaluate this effect to understand revisions in their
     UPL calculations
                                                                                 70
Medicaid Related Issues: Case-Mix

• For purposes of Medicaid reimbursement, states utilize a myriad of
  different payment methodologies to determine payment for NF patients.
   – Some states use a version of the RUG-III or RUG-IV models as the
      basis for patient classification and case-mix determinations

• With PDPM implementation, CMS will continue to report RUG-III and
  RUG-IV HIPPS codes, based on state requirements, in Item Z0200,
  through 9/30/2020.

• Case-mix states also may rely on PPS assessments to capture changes in
  patient case-mix, including scheduled and unscheduled assessments.
   – As of October 1, 2019, all scheduled PPS assessments (except the 5-
      day) and all current unscheduled PPS assessments will be retired
   – To fill this gap in assessments, CMS will introduce the Optional State
      Assessment (OSA), which may be required by states for NFs to report
      changes in patient status, consistent with their case-mix rules

                                                                          71
Resources

• PDPM website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
  Payment/SNFPPS/PDPM.html

• For questions related to PDPM implementation and policy:
   – PDPM@cms.hhs.gov

• For questions related to the OSA:
   – OSAMedicaidinfo@cms.hhs.gov

                                                                     72
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